The trend of normal vaginal delivery and cesarean sections before and after implementing the health system transformation plan based on ICD‐10 in the northeast of Iran: A cross‐sectional study

Abstract Background and Aims Concerning the growing rate of cesarean sections (CSs) worldwide, encouraging normal vaginal deliveries (NVDs) and mitigating CS rates is a necessity. This study investigated the status of delivery in hospitals affiliated with the Mashhad University of Medical Sciences (MUMS) before and after implementing health system transformation plan (HSTP). Methods A cross‐sectional study was conducted in 2017 in the obstetrics and gynecology ward in four MUMS teaching hospitals. Data were extracted from hospital information systems (HISs) based on the International Classification of Diseases (ICD‐10) and analyzed in SPSS VE10 software. Results The results revealed a significant difference between the rate of NVDs and CSs before and after HSTP, such that implementing this plan in MUMS hospitals has raised the rate of NVDs by 4%. Except for the age groups of less than 15 and 36–40 years, the difference between NVD and CS was significant in different age groups before and after HSTP. The rate of NVD significantly increased within 2 months after implementing HSTP. Furthermore, the difference in the rate of previous CS before and after implementing HSTP was significant (p < 0.001). Conclusion The results of this study show the positive impact of the implementation of the HSTP on CS reduction and NVD increase in the studied hospitals. Since the studied hospitals were teaching and concerning the different costs of NVD and CS between the public and private hospitals, it is recommended to study all hospitals with the obstetrics and gynecology ward to precisely assess the success of HSTP in encouraging NVD.


| INTRODUCTION
Health is among the most critical pillars of social and economic progress.
A central health indicator in any country is maternal health. According to World Health Organization (WHO) guidelines, nations must enhance maternal and infant health by diminishing cesarean sections (CSs) rates. 1 In Iran, the maternal mortality rate (MMR) has dropped by 72%, that is, from 83 deaths per 100,000 live births in 1990 to 23 deaths in 2013.
However, it is vital to develop programs to enhance maternal health in the country. 2 In recent decades, the CS rate has grown immensely in middle-and high-income nations worldwide. 3,4 According to the WHO report, the standard CS rate was found in only 14 countries out of 137 in 2010. 5 According to the Iranian Ministry of Health and Medical Education (MHME), the CS rate has risen from 40.7% in 2005 to 53% in 2014. 6 It is much higher in private hospitals and reaches 90%. 7 According to the WHO report, the CS rate should not exceed 15% of all deliveries. 8 However, research has reported a higher CS incidence in Iran. 9 Despite the declining trend in MMR in Iran from 1990 to 2013, CS outcomes still account for most maternal mortality in the country. 2 While, if conducted correctly and at the right time, CS can avoid mortality and other severe outcomes among mothers and infants, evidence suggests that CS may predispose healthy women and infants to increased mortality risk. 10 Unnecessary CS leads to increased complications among mothers and fetuses and imposes remarkable health care costs. 11 Many studies have shown that women who undergo CS unnecessarily are at high risk of complications and death. 12 In addition, CS infants are more likely to develop respiratory problems, obesity, and other metabolic conditions. 13 The CS rate exceeds its threshold, and no sufficient data supports CS benefits for both mothers and infants. 14 A needless CS is a classic example of the gap between evidence and practice in women's health and delivery. In developing nations, maternal and infant health enhancements rely on upgrading health systems. In cases of rare resources, the increased CS trend leads to a further shortage of resources. 15 Lack of sufficient information about CS outcomes, fear of pain, psychological stress, and short delivery times substantially contribute to undergoing CS. 16,17 Improving the quality of health care during delivery is crucial to diminishing morbidity and mortality in mothers and infants, while CS is associated with higher risks for the disease than vaginal delivery. 18 Iranian health policymakers and decision-makers have proposed multiple plans to reduce the CS rate in the country. 19 Encouraging normal vaginal deliveries (NVDs) is among the MHME's top priorities, aiming to ensure the quality of maternal care. 14 The Iranian MHME has developed a health system transformation plan (HSTP) to encourage NVD and improve maternal and infant health in public hospitals. This plan has been implemented nationwide since May 5, 2014. According to the HSTP, all hospitals must reduce CS rates by 10% per year. Other HSTP goals include population growth supported by health insurance, improving the quality of care in MHME hospitals, cutting health care costs, and updating treatment tariffs proportional to the actual value of services. 20 In addition, the plan to promote NVD was implemented on April 5, 2014, in all MHME hospitals. Declining the CS rate to enhance maternal and neonatal health indicators was among the NVD objectives . The NVD program sought to reduce CS rates by 10%   by 2015, keep privacy, provide more convenient delivery rooms to   increase maternal satisfaction, motivate obstetricians and midwives   with incentive tariffs for vaginal deliveries, and pay anesthesiologists for painless deliveries. 21 Therefore, NVD was conducted freely in public hospitals. The NVD program further focused on using pharmaceutical and nonpharmacological methods to reduce pain by encouraging public agencies and service providers. Delivery preparation courses were provided for pregnant mothers to encourage the culture of pregnancy and childbirth while simultaneously supporting health care providers to promote NVD.
Although the impact of HSTP on CS reduction has been studied in some cities, including Qom 22 and Kerman. 23 However, no study has been conducted to investigate the effect of reducing CSs before

| Data collection
The main categories, subcategories, and codes relevant to each type of delivery and the delivery outcome, including single or multiple births, alive or dead baby deliveries, and the place of birth, were Data were extracted from the hospital information system (HIS), as assisted by the Department of Health Information Management in teaching hospitals. First, the data were cleaned. In the first step, the data was screened for possible duplicates based on the national identity, medical record number, age, and date of admission. Then the cases with incomplete or wrongly registered ICD-10 codes of delivery were omitted. Furthermore, any records with incorrect information due to incorrect coding were removed.

| Statistical analysis
In this study, HSTP independent variables and ICD-10 codes related to the status of delivery were considered dependent variables. The records were coded, and the data were entered and analyzed using  The mean age of the women attending the study was 28 years, ranging from 10 to 65. Of all mothers, 11.7% were under 20 years old, 76.7% were 20-35 years old, and 11.6% were over 36 years old ( Table 1).
The nonparametric χ 2 test was used to test the difference between the number of NVDs and CS deliveries before and after implementing HSTP. With a 99% probability, the difference between the number of NVDs and CS deliveries following the implementing HSTP was significant (p < 0.001) ( (p < 0.37), or 40-36 years (p < 0.053). After implementing the plan, improvements in NVD rates were observed in mothers over 31 years of age (Table 3).
According to Figure 1, when comparing the monthly number of NVDs and CS deliveries during the 6 months before and after the HSTP, the rate of deliveries during the first 2 months after the HSTP differed significantly from the corresponding period before the plan.
The number of NVDs increased by 2% within 5 months after implementing the plan, that is, from the second half of October to the second half of November in 2014 (Table 4).
There was no significant difference in the number of single   According to the Iranian MHME, the CS rate in Iran has decreased by 6.5%. These findings indicate much lower rates of CS in Mashhad teaching hospitals than in other hospitals in the country.
Since the study has covered teaching hospitals in Mashhad, the impact of the NVD program on promoting NVD is more likely to be lower in big cities than in small towns.      27,28 and being available at any time and place. 29,30 Mathers' demand is an influential factor in increasing CS rates.
Therefore, educating and promoting mothers' awareness of CS risks, NVD benefits, and effective, painless delivery methods will efficiently reduce CS rates. 31 An MHME's policy to promote vaginal delivery is to promote uncomplicated childbirth, which has significantly contributed to increasing the number of vaginal deliveries. 1  According to studies, one of the main reasons for CS is a history of previous CS delivery. 31

| Strengths and limitations
This study epidemiologically investigated deliveries based on the ICD-10 system. Hence, deliveries were classified based on a coherent and reliable classification system. Also, examining the existing conditions based on an international tool helps to create a unified picture of errors and how to handle them. 34,35 This work was a multicenter study, thus allowing generalization of the results. However, there were some limitations. First, the study was carried out in MUMS teaching hospitals, and the status of other centers and private hospitals remains unclear.
Second, we failed to compare our results with the findings of other countries because of the lack of similar research. Third, the quality of coding was not examined in this study. However, considering that the process of coding medical records in the hospitals under study was done by clinical experts, and then the quality of the codes is examined by HIM experts in the coding department. The authors assumed the high accuracy and adequacy of the assigned codes.